Implementation Research for Vulnerable Women in South Africa

描述（由申请人提供）：最近估计南非妇女艾滋病毒感染率超过40%。在南非，感染艾滋病毒或有感染艾滋病毒风险的弱势妇女由于性别暴力以及酗酒和使用其他药物而面临保护自己的障碍。AOD的使用降低了艾滋病毒检测的可能性，降低了接受检测的人获得抗逆转录病毒治疗（ART）的可能性，并降低了接受抗逆转录病毒治疗的人的依从性。AOD的使用还增加了可能传播艾滋病毒的行为。尽管艾滋病毒感染妇女使用抗艾滋病药物普遍存在负面影响，但提供艾滋病毒咨询和检测（HCT）或产前护理的卫生诊所、药物滥用康复诊所或艾滋病毒临床护理很少使用循证干预措施（EBI）来解决这一问题。自2001年以来，我们为妇女调整和实施了一项全面的EBI，即妇女健康合作社，解决酒精和非酒精使用、性风险和性别暴力问题。它包括一个个性化的行动计划，包括与抗逆转录病毒疗法、药物滥用治疗或住房等其他环境需求等卫生服务的联系。世界遗产中心被列入美援署《非洲性别研究简编》。我们将这种干预措施打包，用于培训培训员，并准备将其纳入日常护理，以帮助解决弱势妇女面临的许多问题。因此，我们的建议是确保在更大规模扩大之前取得成功的下一个合乎逻辑的步骤。这个建议的R01项目寻求开发和测试集成EBI的实现策略。我们将使用形成性方法与社区妇女，我们的社区咨询委员会，诊所工作人员和管理人员合作，制定和实施营销计划，解决将WHC整合到提供产前或HCT服务的常规护理健康中心以及药物滥用康复中心（康复中心）的挑战。形成性工作的结果将指导一系列迭代试点研究的实施，使用阶梯楔形设计来评估实施和患者结局。 具体目标：我们的具体目标包括以下几点：目标1.制定，实施和评估营销计划的适当性，以促进进入卫生中心和康复场所实施WHC。目标2.通过跨健康和康复诊所的阶梯楔形设计提供WHC，以评估实施情况（可接受性，采用率，成本，保真度，渗透率和可持续性）和服务成果（全面服务和及时的服务联系）。目标3.在6个月随访时评估WHC患者结局（有效性、满意度）。在通常的护理环境中实施EBI，以接触更脆弱的艾滋病毒阳性的使用AOD的妇女，如果能够成功实施并在现实环境中证明是有效和可持续的，则可能会产生很大的公共卫生影响。

DESCRIPTION (provided by applicant): Recent estimates of HIV prevalence among women in South Africa exceed 40%. Vulnerable women living with HIV or at risk of HIV in South Africa face barriers to protecting themselves because of gender-based violence (GBV) and alcohol and other drug (AOD) use. AOD use reduces the likelihood of testing for HIV and access to antiretroviral therapy (ART) among those who are tested and reduces adherence among those who are on ART. AOD use also increases behaviors that may transmit HIV. Despite the pervasive negative impact of AOD use among women living with HIV, very few health clinics that provide HIV counseling and testing (HCT) or antenatal care, substance abuse rehabilitation clinics, or HIV clinical care use evidence- based interventions (EBIs) to address this problem. Since 2001, we have adapted and conducted a comprehensive EBI for women, the Women's Health CoOp (WHC), that addresses alcohol AOD use, sexual risk, and GBV. It incorporates a personalized action plan complete with linkages for health services like ART, substance abuse treatment, or other environmental needs such as housing. The WHC was listed in the USAID Compendium of Gender Studies in Africa. We packaged this intervention for training of trainers and it is poised to be integrated into usual care to help address many of the issues facing vulnerable women. Consequently, our proposal is the next logical step to ensure its success before a larger scale-up can occur. This proposed R01 project seeks to develop and test an implementation strategy for integrating an EBI. We will use formative methods to collaborate with community women, our Community Advisory Boards, clinic staff, and administrators to develop and implement a marketing plan that addresses the challenges of integrating the WHC into usual care health centers where antenatal or HCT services are provided and into substance abuse rehabilitation centers (rehab). The findings from the formative work will guide the implementation in a series of iterative pilot studies using a stepped-wedge design to evaluate the implementation and patient outcomes. Specific Aims: Our specific aims include the following: Aim 1. Develop, implement, and assess the appropriateness of a marketing plan to facilitate entry into health centers and rehab sites for the implementation of the WHC. Aim 2. Deliver the WHC via a stepped-wedge design across health and rehab clinics to evaluate implementation (acceptability, adoption, cost, fidelity, penetration, and sustainability) and service outcomes (comprehensive services and timely service linkages). Aim 3. Assess WHC patient outcomes (effectiveness, satisfaction) at 6-month follow-up. Implementing an EBI in usual care settings to reach more vulnerable AOD-using women who are HIV+ has potentially high public health impact if it can be implemented successfully and shown to be effective and sustainable in real-world settings.